Daily Archives: December 10, 2007

Patient Presentation A 3-year-old female came to clinic for her health supervision visit. The resident physician noted that the preschooler was due for her second Hepatitis A and Influenza vaccines.
Her mother said, “I know that most of the thimerosal has been taken out of the vaccines, but do they still have preservatives in them?” The resident stated that he wasn’t sure but would find out for the mother before ordering the vaccines.
When discussing the healthy child with his attending physician, the resident said that he wasn’t sure where to find the preservative information.
The attending physician offered several suggestions including checking the American Academy of Pediatrics RedBook®, looking at the package inserts that the nursing staff kept easily available where they prepared the vaccines, and also looking at the U.S. Food and Drug Administration’s website.
Together the resident and attending physician looked up information about thimerosal and also the other preservatives in currently licensed vaccines.
The Hepatitis A vaccine (Havrix®) contained 2-phenoxyethanol but the Influenza vaccine (FluMist®) did not. Both did not contain thimerosal.
The diagnosis of a healthy preschooler was confirmed by the attending physician. During the discussion about the preservatives, the mother decided to have her daughter receive both vaccines.

DiscussionPreservatives in vaccines and other biological products are used to prevent growth or kill microorganisms especially bacteria and fungi that could accidentally contaminate the product prior to administration.
While preservatives can decrease the risk of contamination, especially in multi-dose vials, they cannot completely eliminate the risk.

Thimerosal has been used as a preservative for many years and is approximately 50% mercury by weight. It is metabolized into ethyl mercury and thiosalicylate. Ethyl mercury is an organomercurial that is related, but distinctive from, methylmercury.
Methylmercury is a known neurotoxin and most exposure comes through food.

Because of potential concerns about thimerosal as a preservative, especially neurocognitive concerns, manufacturers have decreased or eliminated thimerosal as a preservative in many vaccines and other biological agents.
The Institute of Medicine Immunization Safety Review Committee issued a report in 2004 which concluded that the evidence “??? favors rejection of a causal relationship between thimerosal-containing vaccines and autism, and that hypotheses generated to date concerning a biological mechanism for such causality are theoretical only. The committee also stated “???that the benefits of vaccination are proven and the hypothesis of susceptible populations is presently speculative, and that widespread rejection of vaccines would lead to increase in incidence of serious infectious diseases like measles, whooping cough and Hib bacterial meningitis.”

Learning PointPreservatives used in vaccines licensed in the U.S.

2- Phenoxyethanol

DTaP – Infranix by GlaxoSmithKline Biologicals

Hepatitis A – Havrix by GlaxoSmithKline Biologicals

Hepatitis A/Hepatitis B – Twinrix by GlaxoSmithKline Biologicals

2 -Phenoxyethanol and formaldehyde

DTaP – Daptacel by Sanofi Pasteur, Ltd

Inactivated Poliovirus – IPOL by Sanofi Pasteur, SA

Benzethonium chloride (Phemerol)

Anthrax – Biothrax by BioPort Corporation

Phenol

Pneumococcal Polysaccaride – Pneumovax 23 by Merck and Co., Inc.

Typhoid Vi Polysaccaride – Typhim Vi by Sanofi Pasteur, SA

Thimerosal

DT

Td – several manufacturers

TT – several manufacturers

Influenza – several manufacturers

Thimerosal-free vaccines for vaccines routinely recommended for children under 6 years of age

Patient Care
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
8. Health care services aimed at preventing health problems or maintaining health are provided.

Medical Knowledge
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

Practice Based Learning and Improvement
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.

Interpersonal and Communication Skills
17. A therapeutic and ethically sound relationship with patients is created and sustained.
18. Using effective nonverbal, explanatory, questioning, and writing skills, the healthcare professional uses effective listening skills and elicits and provides information.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.

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